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IT SELF DECLARATION FORM ENG

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ATTACHMENT 1 - SELF –DECLARATION
SELF DECLARATION COVID – 19
(to be delivered to the air carrier - write in block letters)
THE UNDERSIGNED (LAST NAME AND FIRST NAME)
NATIONALITY
, BORN IN
ON
WITH PASSPORT/DOCUMENT N..
ISSUED ON
BY
RESIDENT______________________
DECLARES UNDER ITS OWN LIABILITY, PURSUANT TO THE REGULATION IN FORCE, AS FOLLOWS:
1) Not to be affected by COVID-19 or not to be subjected to a mandatory quarantine period of at least 14
days;
2) Not to be currently suffering from fever with a temperature above 37,5° C;
3) Not to accuse at the moment persistent cough, difficulty breathing, cold, sore throat, headache, severe
weakness (tiredness), decrease or loss of smell/taste, diarrhea;
4) Not having had close contacts with person affected by COVID-19 since two days before the occurrence
of symptoms and up to 14 days after the occurrence of the symptoms.
I also undertake to inform the air carrier and Local Health Authority of any possible occurrence of above
mentioned symptoms arising within eight days of disembarkation from the aircraft.
In order to allow the traceability of the undersigned in the following 14 days from the arrival in Italy, here below
I report my residential address /telephone/mobile number /e-mail account
CITY
, PROVINCE
ADDRESS
HOUSE NUMBER
TELEPHONE/MOBILE
Date and place :
ZIP CODE
e-mail
,
Legible signature of the declarant
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